Provider Demographics
NPI:1588948798
Name:AYUKOKATA, SUSAN OTANG
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:OTANG
Last Name:AYUKOKATA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:OTANG
Other - Last Name:ENOW ASHU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHARM D
Mailing Address - Street 1:295 WHALEYS LAKE DR
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30238-4872
Mailing Address - Country:US
Mailing Address - Phone:404-428-5808
Mailing Address - Fax:770-603-2738
Practice Address - Street 1:500 BROOKHAVEN AVE NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30319-3291
Practice Address - Country:US
Practice Address - Phone:404-460-1924
Practice Address - Fax:404-460-1921
Is Sole Proprietor?:No
Enumeration Date:2011-10-06
Last Update Date:2011-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH023277183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist